Document Z4XkqDxqo7X4B1wJv4ox8vMd

&4U- .. . : j !'.,li^@M.v: ----C^V>`V' /^'rfSr Development of a Medical Program T- for Small Plants !" HAROLD D. BELK, M.D., Winston-Salem, N. C. vil i-r fcsfo t?r Kt !&: " TiM ' g#; W0T l-sfe PM^ser*^*l'tv''''' i' V\ ;s --> f " 8 ' ^ vif r**c<z 1**. . tronc socioeconomic influences are operat Robertson to the National Health Forum in " S ing today to encourage the establishment of 1959s as contributing to the retardation in the v in-plant medical services. Coverage under workdevelopment of medical facilities. First, the men's compensation is being broadened to en small business manager often has litde time for compass more and more entities. There is an long-range planning after groping for answers i -incfeasing tendency toward liberalization in to immediate needs--sales, production, operat-' interpretation of the intent of these laws as they ing capital. Secondly, the small plant often \ apply to the workers relation with his em cannot provide individuals specialized in pro- ; ployer. Benefits, too, are being revised upward duction and staff functions to fill positions of . as the cost of living rises. .. responsibility; therefore, managers may be re- V. The cost of providing health insurance as a quired to make decisions,without.benefit of v fringe benefit has been increasing. Between . specialized insight into the problems. Thirdly," ., 1950 and 1963 the average daily cost of hospital records of small plants, because of a lack of * ' charges increased 1382, in comparison to an. in systematic entries, often do not indicate that the ffcrease of 272 in the over-all cost-of-living index plant has -a problem regarding compensation ` in die same period.1 A third and potentially powerful influence is present in temporary disability insurance laws which had been enacted in 4 states by 1952 costs, absenteeism, and labor turnover. .. There are other obstacles to the acceptance of in-plant medical services that are not neces- / sarily related-to the size of the plant! An im- Ht VV%. 8 i r. i (Rhode Island, California, New York, and New Jersey). This legislation provides partial com pensation for wage loss resulting from non industrial illness. The tendency has been to re quire: that the employer bear at least part of die cost'of the program.* portant one is a lack of understanding of the cost of such a program. Too often the short- ^ t'i 1 term cost of initiating and operating an in-plant .-/ IIpreventive medical service is considered pro-,,v' hibitive, particularly when management has lit- ;> f - tie understanding of the .increased long-term : cost of loss opifficiency which*is aggravated by V' Obstacles to Small-Plant Programs f In spite of these increasing economic pres; sures, small-plant operators have shown litde in. terest in establishing in-plant medical.programs to help deal with employee health problems. (A small plant is defined here as one which em ploys 500 or fewer workers.) Several problems peculiar to small plants were pointed out by Dr. Belle fa Director, Medical Department, Western Electric Co, Winston-Salem. This presentation was the winning manuscript in the chronic health problems and unsafe and un- ' healthy work environments. V A second general obstacle is a lack of under- \ standing of the function of a program of pre vention and health maintenance. This lack is'v not necessarily limited to management. AIJ too often die private practitioner feels he has ful- filled his obligation to the patient after he has r rendered reparative services. There is litde ap preciation of, and therefore litde interest in, preventing recurrences of the problem or injury. A third obstade`mty be present in the gen- i ' Central States Society of Industrial Medicine. and Surgery . Contest, at which time the author was a resident in occupational medicine at Ohio State University-and AT&T Co*. . * t , eral philosophy of management toward the em- v. $ployees. Often there is a feeling that the obli- i..1 gation to the health needs of the employees is ^ 460 k 409680 0148 *--- <'Vol. No. nbor 1944 BELK 461 y satisfied when workmen's compensation bene- is^is, as Pre?crfbed hy law, are provided.4 'A fourth obstacle is the general lack of infor- tice. The 2 physicians whose activities were studied freely offered their time and effort to /V--: :.v *. /= . ' -V' provide records and answer questions r< ..-'i; ' matron concerning the experience of others with procedures and policies. After being {Vemployee health .programs. Few papers have that the plants would not be identified by name I; been published in recent years showing the cost or location, the executives from each plant , .i/. and scope of such programs, die turnover rate, jp:compensation costs, and absenteeism of indus- tries with active employee health programs. promptly gave permission to this observer to use data describing the setting in which the medical service functioned and the services pro : ' v~ *A fifth obstacle is die lack of effective means vided by the medical program. (For protection * of communicating information already available of the privacy of the physicians and plants in . to industrial management. Results from a study volved in this study the senior physician will X of managerial attitudes* show that managers are be referred to as Dr. A; the junior, as Dr. B.) , ? most likely to be influenced by industry sources (conversation with other businessmen in the same industry, conventions and meetings with in the same industry, visits to other industries , of the same type, and journals of the same in i'' dustry). - Yet, in the study, no relation was t demonstrated between die importance attached to industry sources and willingness to institute health programs. This would indicate that po- V tential industry sources have not been utilized S.. effectively to encourage establishment of health v services. " *` Development of the Program / The industrial office developed in a city lo cated in the northern half of a highly popu lated, industrialized midwestern state. Popula tion growth of the city has been constant for every decade in this century except for. the 10year period of the thirties. During the 19S0's there was a gain in population of 8.79%, to give an official census figure of 37,079 in 1960. County population in 1960 was officially 60,221. Since 1950, 9 manufacturing industries have i- 4* *- 1 4 V .-* ; 'v 7 * /. Types of Programs ......,________ '. . instituted operations in the local area. Three of i ? ... No single.-type of" arrangement for develop- these plants employ 500 or more workers; die ' . ment of in-plant medical services has gained remaining 6 employ less than 100. By 1964, the a widespread acceptance either .by medical per- 9 employed approximately 2300 workers, more sonnel or by small industries. The most pub than one-third of the 6476 workers employed in i licized types of in-plant programs have been manufacturing industry in June 1964 (local area - sponsored by groups of small industries alone chamber of commerce estimate). In-plant medi or in conjunction with local or state govem- cal programs have been developed in 2 of the mental agencies.8, T-8 These programs, however,. plants employing approximately 500 workers seem not to have been widely popular because each. of either lack of appeal to the physician or se The county is served by 56 physicians, and vere restriction of quality or depth of services almost all medical specialties are represented. offered, for there have been no recent attempts Two hospitals with bed capacities of-J.66 and ?: .to extend this type of service in other commu- 60 are located in the community. \ nities. The industrial medical practice developed t- Because of the generally unsatisfactory state from a practice of general medicine and surgery :'* of in-plant programs in small plants and because which also included treatment and care of pa _Y - almost no attention has been given programs developed .by private physicians, it was deemed worth while to undertake a descriptive study of tients who had sustained occupational illnesses and injuries. This practice was assumed by Dr. A in 1947 upon the retirement of his father from '.J - : -* ' the program and services of 2 physicians who active practice. From the beginning of his prac ' do provide central medical facilities for treat tice, Dr. A was interested in the treatment of ment of industrial injuries and illnesses and who industrial illnesses and injuries. Under the in have developed in-plant programs. fluence of a physician from an industrial clinic , A Model Program in a nearby metropolitan -area; he decided to confine his activity to treatment of these ill or -.V Several months were spent both observing injured workers. Over the next 2 years he grad and participating in the in-plant and office prac- S- ually referred his private patients to other physi- .i l^ 409680 0149 462 SMALL-PLANT MEDICAL PROGRAM . : Journal of Occupational MoJidno . cians in the community to limit his interests to cuss this service at a safety meeting-m;- their industrial cases. ooiimiunity. During these formative-years. Dr. A utilized About 2 years earlier, in 1958, Dr.Ahad felt- 3 basic approaches to his practice: (1) He made that the demand for in-plant services lirid lri- ai himself readily available at all times to provide creased to the point that this demand would te-?- treatment in industrial injury cases. (2) He quire the full-time attention of a paitner.Dr. A;: utilized every opportunity to visit the plants to believed that for maximal development .of these/ analyze the mechanics of the accidental injuries .in-plant services his prospective partner should which occurred and to examine methods of pre be specifically trained to conduct m-plant medi- ; vention with management; additionally, he cal programs. In June 1961, Dr. B, who . had visited the plant to examine prospective jobs just completed a 3-year residency in occupa for individuals returning to work following in-; tional medicine, agreed to establish an in-plant juries. (3) He.regularly attended safety meet program in Plants A, B, and C by visiting each ings arid frequently was asked to speak on medi plant 2-3 hr. once a week while he remained on cal problems regularly encountered in the work the staff of the school where he received his. place. As a result, safety councils in surrounding training. communities often requested his services for After 1 year Dr. B decided to devote full-time speaking engagements. to die development of in-plant programs in the Gradually, over die years, the patient load -- increased, as established industry expanded and new industry moved into the area. An addition al important aspect of the increased activity local area by joining in equal partnership with Dr. A. In 1964 Dr. B was certified in Occupa tional Medicine by the American Board of Pre ventive Medicine. in die office was the expansion of services of fered in pre-employment examinations, retum- The Industrial Medical Office to-work examinations, and annual executive examinations. More and more industries made use of the facility as management of the plants slowly began to accept .the usefulness of a few basic preventive services. Important, too, to industry was the utilization of a physician who had developed a more thorough understanding of workmens compensation laws than was gen erally present in the medical community. The present office building,''constructed in I960, is located in ari easily accessible location 4 blocks from the downtown area. The build ing is shared with other physicians, but approxi mately one-half the space is utilised by Dr. A Four persons are employed full-time in the office. A technician performs preliminary, test ing in the physical examination section. A full time secretary and receptionist for Dr. A bills In' 1958, Dr. A began visiting die in-plant the industrial commission or specific industries medical facility of Plant D (see Table 1) for for services or treatment of employees. Two 1 hr. 5 times weekly. An in-plant -medical graduate nurses work full time. The activities: dispensary already existed here; it-had been of one are confined to the physical therapy sec served/by a full-time staff physician who re tion, and the second assists Dr. A in the treat signed to assume another position. The follow ment area^by offering' technical assistance, ing year. Dr. A began to visit Plant G (see cleaning and stocking supplies, and taking and Table 1) for 3-4 hr. per week Services to these processing X-ray films. A part-time secretary is plants were on a fee-for-service basis and con available 4 hours daily for Dr. B. sisted primarily of treatment of injuries, pre Four types of physical examinations are per employment examinations, and retum-to-work examinations with placement of employees on jobs consistent with their ability to perform. formed in the office. The most frequently per formed examination is the pre-employment, which is required by all major companies in the community. Those companies without in-plant j ?;. By 1960 Dr. A could not assume any further programs also utilize the office for "special" responsibilities although he had been ap examinations for employees returning to work proached by management of Plants A and B, following illness or injury. Six companies pro located 18 and 22 miles from the office, request- vided annual executive physical examinations i ing that he establish in-plant programs for them. for top management in 1963, while only 2 com Manageriient of these plants had become inter panies required periodic examinations for ested in such a program by hearing Dr. A dis workers exposed to occupational hazards. 409680 0150 If >... . ' BELK : .i-ytr-; ` Occupationallyinjuredjbr ill patients from all Plants with Medical Programs ^plants in the area are'usually diagnosed and vf treated in the . office. This service is also ex pended to the plants in which in-plant medical ^' programs have been established, unless the in. ^juiy is minor and;can "be effectively'managed 'J-by the medical service in the plant Most of 'the other small miscellaneous businesses in the area, from grocery markets.to construction com panies, encourage their employees to utilize the \f office for treatment Coverage for treatment of emergencies which arise during nonoffice hours'is provided on a vhS'calT' basis by Drs. A and B. Coverage by each ^individual extends oyer the period of a week <rand is facilitates! by an extension of the office |?phone in the homes of both. At weekly intervals, the original copies of the ^.examination forms (pre-employment "special," s-and periodic occupational) are .mailed to the ^medical departments of plants which have re^ ferred the individuals, to be incorporated into V the employee's medical record A copy is reV tained in the' office of Drs. A and B in the indi- The location and type of operation for plants with in-plant medical programs are presented in Table 1. Data showing employment,* turnover, number of accidents, and workmen's compensation rat ings for plants with medical programs are pre sented in Table 2. No attempt has been made in the presentation of the data to trace changes in employment and accident patterns which have occurred in recent years because records have undergone changes and the medical pro gram in none of the plants could be expected to exert a maximal influence at this time. * Average monthly shop and salaried employ ment was obtained by calculating average em ployment for the month from weekly reports from the personnel offices. Monthly employ ment was then averaged for the year. - Percentage of additions (or separations) was obtained by the following formula: I X 100 E r-vidual's file. The original form of the executive where I is the number of individuals hired or ... examination is retained in the office, thet,first returned to work (or dismissed or "laid off"), . r carbon is given to the examinee for"Kis physi- and E is the average monthly shop employment cian, and the^second carbon is sent to the plant for the year. Many plants had very high turn for inclusion iri medical records there. over rates. Frequent temporary suspensions 'V. Liaison between the office and the plants with ^ .medical programs is maintained by periodic photocopies of the employee's office record of treatment for injury or illness. These copies are with subsequent return to work operated to pro duce these elevations in most instances. Monthly total absenteeism percentages were obtained as follows: .; sent only to plants with medical departments for inclusion in the medical record. Abu X 100 WM x Emp. i: t0s A Plant TABLE 1. Operations in Plants with Medical Procrams Location Shop* Products X A B C D E F C H I 22 miles from office 18 miles from office In town with Plant A In town with office In town with office I n town with office In town with office In town with office ! 5 miles from office in rural area Foundry, machine shop, assembly area Machine shop, assembly area Machine shop, assembly area, paint shop Machine shop, fabrication shop Assembly and erector shops Foundry Forge shop, machine shop Machine shop, assembly shop Wire-braiding area, "curing" ovens Heavy road-building equipment Heavy road-building equipment Steel burial vaults, steel truck bodies --dump trucks, garbage trucks, etc. Heavy earth-moving machinery Heavy earth-moving machinery Castings for Plant D Automotive parts--axles, brake units, clutches, eta Air-conditioning compressors, refriger ation units ' Reinforced tubing for hydraulic lines Plants A mod n are divisions of I company and Plants D, E, and F are divisions of another. /: r;- ` tr V j 1 1 . j j * 't 409680 0151 ri % 464 SMALL-PLANT MEDICAL PROGRAM 0u3.ted Plant A B C D E F C H I TABLE 2. Data on1 Personnel, Safety, and Workmens Compensation , in Plants with Medical Programs J*} Employment, 1964 (monthly or.) Shop Salaried Tmmovrr, thop, J964 Addit, <%) Separate i%) Abeenieeiem, av. %) . Loet-time . sccldemte, 1969 No. Freq. rate 335 187 1.8 1.8 3.2 23 23.76 124 12 15.4 15 2.4 13 NA*t 322 164 .42 39 5.6 25 286 893 510 54.8 39.3 NA 22 6.88 219 20 72.4 46.3 NA 6 24.97 217 55 46.2 40.1 NA 8 15.15 344 92 22.9 17.0 4.1 20 22.61 664 . 78 30.1 17.3 3.7 42 NAfl 375 85 2.0 2.0 2.9 4 4.05 comp. nurit rating 1S63 <%) , +26 +26t +33 +10*. +10* +10* NA1 NAT! NAS Not available. . . +A and B are divisions of the same company; workmenY compensation ratings and costs are-combined. }D, and F are divisions of the same company; the rating Is combined. {Data presented are for 1964. Data from other years were not available. | Plants G and I and self-insured. ^Workmen's compensation rating and costs are combined with another division in the state. t t a... t-' c I i i i * AbM represents days of absence per month; WM, number of working days per month; and Emp., the average number of employees. The month ly average for the year was then obtained by averaging these monthly percentages. Data were not available for Plants D, E, and F be cause these plants report only the number of different employees absent in a weekly period without an indication of the total days lost due to absence. - Data for numbers of lost-time accidents (ac cidents which did cause or would have caused the absence of the employee from work on the succeeding day), accident frequency rates, and workmens compensation ratings are presented for 1963 because complete data for 1964 were not available when this information was ob tained. The accident frequency rate was ob tained by finding the number of lost time acci dents per million man-hours of work the plant experienced. In-Plant Medical Programs All in-plant medical programs provide these services: 1. Pre-employment examinations 2. Work capacity evaluations for return to work from injury or illness 3. Rehabilitative efforts for victims of oc cupational and nonoccupational illnesses and (injuries by careful job placement and follow-up 4. Individual counseling for health main tenance 5. Treatment of minor injuries 6. Advisement of management in areas of in surance and relations with the medical commu nity .......... ... Usually, pre-employment and retum-to-work ' examinations are done in the industrial medical office for those plants which are located nearby *' (except Plants D, E, and F). .Treatment of \ work-connected illnesses and injuries is also J provided in the office for those plants in the Jo- cal area. Almost all employees from Plants A, | B, and C are'referred to their personal physi- cians for treatment of industrial injuries. ; As management has supported other pro- . grams, these have been instituted. Special ac- * : tivities and costs of the programs are presented ' ' in Table 3. In the computation of the -costs for the inplant medical programs, the. costs for space, i utilities, or depreciation of equipment are not included. Also excluded are the costs to the companies for the treatment of illness or in jury, since outside treatment for employees is provided by Plants A, B, and C. The charges for examinations performed in-the office for these plants is included in this listing, and the cost for supplies is also included, except for Plants D, E, and F, where it could have been obtained only by examining all requisition orders of the company .for the year. Annual costs per employee of the medical . programs for the plants in this study ranged v . from $7.64 to $44.57 (Table 3). The mean cost V 409680 0152 .t^VoC'l No. 4 `Wtmber 1966 r' ^'-v - _ -' BELK 465 employee for all the plants .was $22.38. This also elevated the cost of the program for Plant xnean cost was obtained by dividing the costs G. `of the medical programs for. all the plants Most of the plants have provided space for '($105,080.28) by the total average monthly em a nurse's office, a treatment room, and a combi ployment of shop and salaried workers (4696). nation physician s office-examining room. Noise The elevated cost of the program for Plant F from the plant is a problem in Plants A and B. occurred because there are 2 nurses for a small There are no facilities specifically reserved for employee group and an annual occupational the physician at Plant C. No nursing personnel examination with chest X-ray, which is provided are available here either. A secretary assists Dr. a;*each employee. Full-time coverage by 2 nurses B on his visits, and she maintains records in a fl- TABLE 3. 1964Special Features and Costs of In-Plant Procrams for pw Special feature* Physician's Nurse** Ume time Ann, cost per , (kr./iak.) (hr./xek.) employee () M/a? 3^-.-: . fii and -' 4s?L b f; - *>** " 1. Biweekly surveys for safety hazards n 2. Dust surveys of foundry by State Industrial Hygiene (3 visits A; . Laboratory 1 visit B) 3. Survey each 6 mo. for lead intoxication in painters 4. Educational programs in proper handling techniques 5. Executive examinations Informal surveys for environmental hazards 4 (2 visits) 30 0 21.20 7.64 C. D i.*,I 1. Informal surveys for welding fumes 2. Frequent consultation with safety department for improv- ing safety conditions in'plant 3.' Development of program for notifying medical depart- ment of new materials in plant 10 (5 visits) 120 (3 full-time) 15.59f % E 1. Informal surveys for welding fumes 2. Consultation with management regarding safety hazards 1 40 25.87f F ' 4?*i V? c ><-. fj. *" ... iH V. i`,, - -Jt * ^T. I T~ . 7-. i. Periodic dust counts by State Industrial Hygiene Laboratory 2. Annual physical examination of employees, with chest X-ray _ 3. Periodic executive examinations 1 1. Hearing conservation program with annual audiometric examinations 2. Scheduled programs in proper handling techniques for prevention of injuries 3. Surveying safety hazards with safety personnel 4 (2 visits) 1. Special emphasis upon health counseling because of low educational level of employees 2. Periodic executive examinations 3. Program for prevention of dermatitis 4 (2 visits) 1. Periodic executive examinations 2. Hearing conservation program with periodic audiograms and ear protective programs 3.. Survey of workers each 6 mo. for elevated levels of lead 1 80 80 80 40 44.571 41.40 27.85 18.53 'Plants A and B and divisions of the same company. tThe cost presented does not include that for supplies, since the figures could be obtained only by examining all requisition orders for the plants for 1964. 409680 0153 ft i.ilir. SMALL-PLANT MEDICAL PROCRAM ''-i Journal f Occupational MaJiciao locked file in the personnel department Rec ords at all other plants are maintained in the medical departments. Supplies and equipment are limited in the dispensaries, being confined to those required for a well-stocked first aid unit--cleansing ma terials, antiseptics, and bandaging materials. ' Only in die dispensary of Plant D are supplies provided for repairing lacerations and other treatments. Plant D also has an X-ray machine. Equipment in other plants is confined to that necessary for physical examinations. Summary By 1964, after 2 years of full-time effort. Dr. B had initiated or expanded in-plant programs in 9 plants ranging in size from 140 to 1400 em-ployees. These programs are widely varied in the scope of the preventive measures which they provide. Perhaps the most significant and criti cal progress has been made in improving the attitude of management toward a program of preventive medicine. In the course of this study, several factors in the institution and perpetuation of a medical service for small plants seemed evident: 1. The physician seeking to establish such a service must be professionally interested in both the workplace and the employee. As an in tegral part of the medical program, the physi cian must go into the workplace to enhance his knowledge of job specifications and environ mental hazards. 2. A physician who expects to establish inplant medical programs in small plants must be willing and available to provide immediately and promptly services for treatment of occupa tional injuries and illnesses. 3. The physician must use every opportunity to show both management and the employee the potential which preventive medical programs offer.. 4. The physician must balance the services he proposes to provide to small industry against die specific needs of individual plants and .the willingness or ability of management to provide for these services. In striving to.arrive- at a proper balance, the physician must be careful not to compromise his principles of providing! adequate care and protection for the employee. 5.The physician must establish. In both the industrial and die medical community, his in terest in occupational medicine. Ideally, this ; is accomplished by limiting his activity to treat ment of occupationally induced injuries 'and ill nesses, to providing in-plant services if in de mand, and to offering consultative services to industry. The activities of the 2 independent physi- . cians presented in this study would indicate that initiation of in-plant medical programs in small plants is possible when interest, patience, and perseverance are applied to this perplexing problem. A need in the community is being met Western Electric Co. -. 3300 Lexington Rd. JWinston-Salem, N. C. References.----"- ' . 1. "Health Insurance Viewpoints." Health Insurance Council, New York, December 1964. 2. - Kj.em, M. C., and McKieveh, M. F. Small Plant Health and Medical Programs. Public Health Serv- . ice Publication No. 215, Supt Doc., Washington, D. C., 1952. 3. Matsel, A. Q., Ed. The Health of People Who Work. ThexNational Health Council, New York, 1960. ' 4. Colusson, N. H. Management and an occupa- ' tional health program. Arch Environ Health 2.T16, Feb. 1961. 5. Dickinson-, W. W. A small plant medical service. Arch Industr Health 19:473, May 1959. 6. "Employee Health Services. A Study o Managerial Altitudes arid Evaluations." institute for Social Re search, University of Michigan (for United States Public Health Service), 1957. 7. Smelo, L. The Birmingham industrial council. In-' dustr Med Surg 28:341, July 1959. 8. Industrial health council of Greater Atlanta. Industr Med Surg 26:198, Apr. 1957. n U ii i: DOCTOR'S BUSINESS The higher a patient's income, the more often he is likely to pay a visit to his doctor. A new government survey shows 4.3 visits per person to the doctor each year among those from families with incomes of less than $2,000. When family income jumps to $10,000 or more, the number of visits ii)creases to 5.1 a year. The same survey shows that 2.4 million people--roughly 1.3iSr of the populationhave never turned to a doctor for care or advice. Medical World Netvs 6:169. 1965. 409680 0154 VUVA'.WVtt.kAVtV.WSt*.